Are your residents at risk for impaired healing?

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y far one of the most incriminating intrinsic risk factors for the development of pressure ulcers is malnutrition. Many studies cite a strong link between deteriorating nutritional status and the development and healing of chronic, nonhealing wounds. Up to 85 percent of residents in nursing homes suffer from malnutrition. It is no wonder that this group of individuals is also at highest risk for the development of pressure ulcers.
       A nutritional assessment can help the provider identify whether a patient has nutritional risk factors for impaired wound healing. This article is not meant to take the place of a referral or an assessment by a qualified registered dietitian; however, it can advance our knowledge so we may better care for our long-term care residents by identifying the need for nutritional intervention.
       Wound nutrition is nothing more than whole body nutrition. Residents with severe malnutrition are at higher risk for infection, sepsis, longer length of stay, and ultimately death. Severe protein and calorie malnutrition impairs tissue regeneration, immune function, and the inflammatory response, which is necessary for wound healing.

Identifying Risk
       When is a nutritional assessment indicated? There are many "red flags" to alert the provider to potential risk. An obvious one is involuntary weight loss. Some not so apparent indicators may include impaired cognitive patterns, altered communication/hearing/vision, impaired mood/behavior, and diminished physical and functional capabilities. A Braden scale risk-assessment score below the threshold of 17 or 18 in older populations can indicate risk for development of pressure ulcers. This is an assessment that is most likely already being performed and can serve as an early warning to initiate further nutritional investigation.
       A nutritional assessment looks at four basic categories: A, anthropometric information; B, biochemical data; C, clinical facts; and D, dietary history. A pneumonic to remember these sectors is "Nutritional assessment is as easy as our A-B-C-Ds." Let's look at each of these areas separately.
       Anthropometric information. Anthropometric information is the size, weight, and proportions of the human body. They include weight, body mass index (BMI), triceps skin fold, and mid-arm circumference. Each resident should be weighed at regular intervals. The following is a simple calculation for ideal body weight (IBW):
- Men: base weight of 106 lbs. for first five feet; add six lbs. for every inch over five feet
- Women: base weight of 100 lbs. for first five feet; add five lbs. for every inch over five feet.
       A range of ± 10 percent is considered to account for differences in frame size. For example, a female resident who is five feet three inches tall would have an ideal body weight of 103.5 lbs. to 126.5 lbs. (100 +15 = 115 lbs., -10% = 103.5 lbs., +10% = 126.5 lbs.) Change should be reported as a percentage of ideal body weight. Deficits are graded by using an easy calculation: 100 - [(actual weight ÷ IBW) x 100].
       Deficits are graded as:
- Mild < 5 to 15 percent
- Moderate < 15 to 30 percent
- Severe > 30 percent.
       It is also necessary to obtain a "usual weight," which accounts for weight loss. The calculation for percent of weight loss is (usual body weight - actual body weight) ÷ usual body weight x 100.
       Significant weight loss is considered:
- Greater than five percent in one month
- Greater than 7.5 percent in three months.
       The incidence of unintentional weight loss in nursing homes is greater than 25 percent. Several cross-sectional studies have demonstrated that patients with pressure ulcers weigh significantly less than residents without pressure ulcers.
       Biochemical data. Biochemical data includes laboratory tests, such as serum albumin, serum pre-albumin, serum transferrin, total lymphocyte count, and nitrogen balance.
       Serum albumin. Serum albumin is the major circulating plasma protein synthesized by the liver. It is an inexpensive blood test and common indicator of the resident's protein stores. Its half life (how long it will take before we see decreases in lab data) is about three weeks, so the blood you draw from your resident today will indicate their protein stores from three weeks ago. Mild depletion is considered 3.5gm/100mL. Serum albumin below 3.0gm/dL (hypoalbuminemia) is associated with tissue edema, which further increases risk of pressure ulcers. Serum albumin levels are often used as an indicator of overall nutrition. Low serum albumin increases risk of infection, morbidity, and mortality. It impairs or prevents wound healing and decreases wound tensile strength.
       Serum pre-albumin. Serum pre-albumin is a more sensitive indicator of visceral protein status in acute stages of malnutrition. Its half life is only two to three days and can be helpful to evaluate the adequacy of nutritional therapy. Mild depletion is <15mg/dL. Severe depletion is <5mg/dL. If the resident has chronic renal failure, pre-albumin may be falsely elevated, since it is eliminated in the kidneys.
       Serum transferrin. Serum transferrin has a half life of a little over a week and is an indicator of protein stores as well. A level below 200mg/dL is considered low. This blood test may not be useful in the presence of liver disease or estrogen use, since transferrin levels will be abnormally high. Also of note, liver disease, burns, cortisone or testosterone therapy, and chronic infection can lower serum transferrin levels.
       Total lymphocyte count (TLC). Total lymphocyte count (TLC) reflects the visceral (contained in the body's organs) protein stores of the body and immunity. TLC is more useful as a screening parameter in noncritical individuals. A TLC below 2000 cells/mm3 indicates an impaired immune system.
       Nitrogen balance. Nitrogen balance is also useful for assessment of protein requirements, since protein is 16-percent nitrogen. Nitrogen balance is the difference between nitrogen intake and output. It helps determine needs for protein maintenance and anabolism. Accurate measurements of food and fluid intake over a 24-hour period and a 24-hour continuous urine sample are needed. Nitrogen balance results can be questionable in the presence of renal disease.
       Clinical data. Clinical data includes physical assessment and other information that we are probably already monitoring. These effects include increased metabolic needs, such as fever; infection; trauma; burns; growth; pregnancy; heavily draining wounds; kidney dialysis; chronic diseases, such as diabetes, hypertension, kidney or liver disease, and cancer; gastrointestinal diseases, such as malabsorption, diarrhea, and GI surgery; and physical assessment of gums, skin, face, eyes, mucous membranes, tongue, lips, teeth, and hair. An example of a clinical sign of deficiency is cheilosis, scaly red lips with fissures at the angular corners of the mouth. This may indicate a B2 vitamin deficiency.
       Dietary history. Dietary history includes assessment of the resident's food intake. Assessment questions include, "Have you had any recent changes in your appetite or food intake? Do you have any food allergies, intolerances, or aversions? Do you have any chewing or swallowing problems, nausea, or vomiting? Do you use any vitamin, mineral, or herbal supplements? How much alcohol do you drink? Have you noticed a loss of taste or smell? Do you avoid any specific food groups like meat or have any cultural or religious food limitations?" It is imperative to collect information on what a patient eats as well as any problems that could diminish their nutritional status.

Estimating Nutritional Needs
       After we have performed a nutritional assessment, the next step is devising a plan of attack that includes estimating the nutritional needs of the resident. This includes energy, protein, fluid, vitamins, and minerals.
       Energy. Our bodies are fueled by the energy or calories (kcals) of food. Just like our automobiles require gasoline, some gas is of better quality than others. The same goes for the human body. All food and calories are not created equal. The Harris-Benedict Equation for basal energy needs is used for calculating basal (resting) energy expenditures (BEE). Reports have shown it to be more representative of resting energy needs. There is some controversy among dietitians regarding its use for basal needs. The large difference between male and female BEE is due to differences in muscle mass and metabolic rates. To additionally account for needs beyond resting, we need to use multipliers to calculate for physical activity, surgery, infection, or other injuries, such as pressure ulcers. The Harris-Benedict Equation for BEE of a resting individual is calculated as follows:
- Women: BEE = 655 + (9.6 body weight in kg) + (1.8 x height in cm) - (4.7 x age in years)
- Men: BEE = 66 + (13.6 x body weight in kg) + (5 x height in cm) - (6.8 x age in years).
       Additionally, to account for needs beyond resting, we need to use multipliers to calculate. After calculating the BEE using the Harris-Benedict Equation, the result is multiplied by both an activity factor and a stress factor in order to calculate the resident?s caloric requirements. Some reports have shown that the Harris-Benedict Equation with its activity factors and stress factors may overestimate needs. Harris-Benedict calculation factors are as follows:
- Activity factors:
Ambulatory = 1.3
Bedridden = 1.2
- Stress factors:
Minor surgery = 1.2
Skeletal trauma = 1.35
Major sepsis = 1.6
Severe burns = 2.1.
       The entire equation should look like this: BEE x activity factors x stress factors = resident's total daily caloric requirements.
       Continuous monitoring is essential to evaluate whether a resident's needs are being met. Unless you're a math whiz, you'll need a calculator!
       A quick and easy way to calculate energy needs uses the weight of the resident. In severely malnourished residents, feeding should be gradually increased to prevent problems with refeeding syndrome. Also, avoid overfeeding in metabolically stressed residents. Best practices often dictate utilizing an adjusted weight if the resident is obese.
       Energy expenditure by weight:
- Normal or nonstressed: 20 to 25 kcals/kg body weight
- To heal severe or extensive wounds: 30 to 35 kcals/kg body weight for slightly hypermetabolic or 35 to 40 kcals/kg body weight for severely stressed.
       Protein. Amino acids and protein are the building blocks of collagen. In order for wounds to heal, the body must be in positive nitrogen balance or anabolism, the building phase. Protein needs are calculated by using the following formulas:
- Normal healthy adult: 0.8 grams of protein/kg/day
- Moderate stress (partial-thickness wound): 1.2 to 1.5 grams/kg/day
- Severe stress (full-thickness wound, severe or multiple wounds): 1.5 to 2.0 grams/kg/day.
       Be sure to watch for dehydration when supplementing protein greater than 1.5 grams/kg/day. Fluid needs increase with high supplementation.
       Fluids. Our systems are composed of somewhere between 70- to 80-percent water. We can live for days without food but not without water. Most of our residents are chronically dehydrated. Look for creative ways to increase daily fluid intake, such as frozen popsicles during the hot summer days and hot soup in the cooler months. Fluid needs can be calculated in a couple of ways:
- General recommendation: 1mL/kcal ingested
- Young healthy adults: 35-40mL/kg daily
- Elderly: 30mL/kg daily.
       Be sure to monitor intake and output, especially when the resident has a history of heart or kidney failure. Adequate hydration is necessary to replace losses in residents with draining wounds, residents with fever, or those on high air-loss beds (air-fluidized support surfaces). Also, beware of beverages containing caffeine and alcohol. They act as diuretics and actually cause the resident to lose fluids.
       Vitamins and minerals. Many registered dietitians include multivitamin/mineral supplements as part of their preventative protocol for residents at high risk for ulcers or with existing ulcers. Megadoses should not be administered without the recommendation of a physician or registered dietitian. Consider supplementation of a 100-percent recommended daily allowance (RDA) vitamin/mineral supplement that is automatically incorporated into the care plan. Supplementation beyond the RDA is not advised unless the resident has a known deficiency. Vitamin and mineral assays are useful to confirm suspected deficiencies. This goes for vitamin C and zinc as well. Unless the individual has a known deficit, supplementation has not been shown to be of any benefit.
       If the resident is shown to have a vitamin C deficit, up to 1 to 2 grams of vitamin C may be recommended to promote wound healing. Since vitamin C is water soluble, dietary or supplemental forms must be ingested daily. If there is a zinc deficit uncovered (this is especially true of residents who are vegetarians or who have high-output fistulas or exudating wounds), supplementation with 15-30mg/day is recommended. In residents with normal zinc stores, zinc has not been shown to accelerate wound healing. In fact, too much zinc may interfere with copper metabolism. When supplementing this mineral, have the resident take it with meals to avoid nausea, vomiting, and diarrhea.

Nutritional Intervention and Medical Nutrition Therapy
       What steps must we take when our resident is deficient in calories, protein, fluids, or nutrients? Nutritional intervention and medical diet therapy is required. They include oral feeding and supplements, enteral or tube feeding, parenteral or TPN feeding, and adjunctive therapy, such as anabolic agents. These are directives prescribed by a physician in collaboration with a registered dietitian.
       Oral feeding. The easiest and most pleasant way to supplement is orally. It just happens to be the least expensive and most convenient. Much of our social life revolves around eating. A resident who is unable to take food from the oral route will suffer more than just from gastrointestinal problems and possible malnutrition. Look for foods that the resident enjoys. Make sure they are calorie, vitamin, and protein rich. Offer small frequent meals or snacks. These tend to be much less intimidating than a large meal. Consider adding powdered milk to yogurt and pudding. Have the nutritional sales representatives come in and offer inservices or "tasting parties" where the staff can sample supplemented shakes, cookies, brownies, etc. There are many palatable choices on the market these days. Don't only rely on supplemental shakes. Residents won't eat foods that they don't like. Ask them for input into their supplementation plan.
       One of my favorite stories in my own experiences caring for long-term care residents involved an elderly man whose weight continued to drop despite our efforts to supplement feedings and encourage his appetite. One evening, I sat beside him and quizzed him on what he really enjoyed eating and why his appetite had waned. He told me that he missed his evening treat of M & Ms candy. With that information, I made a quick deal with him. I'd make sure he received a small bag of M & Ms each evening if he additionally drank a 16-oz. glass of milk with it and tried to eat at least 50 percent of each of his meals. I watched in the months ahead as his appetite, weight, and outlook improved! The name of the game is customization when it comes to diet therapy and nutrition.
       Enteral nutrition. If enteral or tube feeding is needed, it can be accomplished with a small-bore feeding tube passed into the nares. This is more comfortable than a nasogastric tube. Placement should always be checked by x-ray before initiating feeding. Mobile residents may prefer bolus feedings (intermittent) instead of continual feedings requiring a pump connection. Many formulas of tube feeding are available for different needs. Certain formulas are higher in protein and fiber or lower in carbohydrates, etc. A registered dietitian (RD) can customize the choice of formula to the resident's needs. Complications of tube feeding include diarrhea, hyperglycemia (high blood sugar), and constipation.
       Total parenteral nutrition (TPN). If the gastrointestinal tract is failing, nonfunctioning, or needs a rest, this is the last resort for nutritional therapy. Since eating has social implications, this can add tremendous stress on the resident. TPN is delivered via a central venous catheter and dramatically increases the chances of infection. It is extremely expensive. The components must be monitored continually, and the tubing must also be changed daily. An intravenous pump must deliver the fluids. This form of nutrition supplies everything that the body needs. The formula is calculated and customized especially for the resident by the RD.
       Adjunctive therapy. Anabolic agents, such as human growth hormone (HGH), although not labeled for this use, are used when a resident has lost 10 percent or more of his or her usual body weight. Its use is contraindicated in residents with diabetes. HGH must be administered parenterally and can cause edema and a 10-percent rise in basal metabolic rate. Testosterone and synthetic derivatives are also used as adjunctive agents. One that is currently being prescribed is oxandrolone.

We are What we Eat!
       Remember, it is always important to treat the resident holistically. We must look at the "whole" patient, not just the "hole" in the patient. If we are not metabolizing (staying constant with regard to nutrition and energy) or anabolizing (building or growing), we are catabolizing (breaking down). In order to prevent or treat existing wounds, it is necessary to offer adequate calories, fluids, proteins, and nutrients while monitoring nutritional risk and assessing nutritional needs. It is recommended to involve a RD in your team assessment and treatment of residents at risk of developing or with existing pressure ulcers. Other things, such as mobility, activity, sensory perception, pressure, shear, friction, and moisture reduction, are all important parts of the equation. Pressure ulcer prevention and treatment should be considered along the continuum of care, which includes nutrition.